Why Was Teen Offered the Wrong Organs?

Published 6:00 pm, Saturday, February 22, 2003

When a heart and matching lungs were donated in Boston two weeks ago, a computer generated a list of patients medically compatible and awaiting transplants.

But the recipient of those organs _ 17-year-old Jesica Santillan _ failed to make the list because, as tragically evident later, her blood type did not match.

How did it happen?

Her family came to the United States from Mexico so she could get a transplant, and she had waited for three years when the organs from Boston became available on Feb. 6.

They came from someone with blood type A. Jesica had type O. Her body rejected the organs, she became critically ill and, despite receiving a second set of organs Thursday, died Saturday.

Officials at Duke University Medical Center in North Carolina have said they failed to ask about the blood type and have taken responsibility for the error.

But why were the first set of organs even offered by transplant coordinators?

Experts in the organ matching system say a mistake like this might occur if a transplant coordinator is having trouble finding a patient who will take the organs.

Despite the acute shortage, some donated organs are damaged, so doctors are reluctant to take them. If they come from a child, as may have been the case here, the organs might be too small for most people on the waiting list.

If a transplant coordinator is having trouble finding a match from the official list of waiting patients, the coordinator might start contacting doctors to see if they have a patient who can use the organs.

"You may call some major (transplant) centers and say, 'I don't want these organs to go to waste. Do you have anybody?'" said Howard Nathan, executive director of the Gift of Life Donor Program in Philadelphia. "The most important thing is to give the organ to a needy patient."

It is not clear what happened in Jesica's case, nor are details known about the donor.

Could someone on the list have benefited from the organs? Were they offered to everyone on the list before Jesica got them? Whatever the rationale, the informal matching used in this instance worries some.

"The way we engender trust is by having a system that's accountable," said Dr. John Holman, a kidney transplant surgeon at the University of Utah. He is chairman of the organ procurement committee for the United Network of Organ Sharing.

The computerized matching system was created "because people were suspected of gaming the system," he said. "It's there to create a sense of fairness."

The transplant network runs the matching system under a contract with the federal government, pairing waiting patients with available organs.

Patients who need transplants are entered into the computer databank along with their blood type, height and weight, how sick they are and the hospital where they are waiting.

Nationally, more than 80,000 people are waiting for hearts, lungs, kidneys, livers and pancreases.

When an organ donor becomes available, information about blood type, size and location are entered into the computer.

A transplant coordinator who is at the hospital with the organ donor requests from the master computer a "match run" _ a list of all patients who are a medical match for that donor. They are listed in order of priority, determined by a combination of how sick they are and how near they are to the donor.

The list of patients can range from tens of thousands to fewer than 10.

Some organs are placed on the first call; others take hours.

In Jesica's case, Duke officials say, transplant coordinators called to offer the heart to two patients. The heart was the wrong size for one, and the other was not medically ready for a transplant.

Jesica's doctor then asked about giving the heart and lungs to Jesica. Although she was not listed on the match run, the transplant coordinator said OK.

Neither the coordinator nor the doctor realized that she was not the right blood type _ the reason she was not on the computer's list of possible patients.

Officials involved in this case have not said whether there were other patients on the match run who might have received the organs.

"It raises the question, can the system be manipulated?" said Charlie Fiske of Boston, who became an advocate for transplant patients after his daughter, then 11 months old, had a liver transplant. "The general public really has to rely on the fact that those things don't happen."

Experts in the system say an organ should never be given to someone who is not on the list. Someone might not be listed, for instance, because they just arrived at the hospital. In that case, they say, the patient should be entered into the computer and the match run should be generated again.

Any aspect of medicine is subject to human error, Holman said, noting that some transplants are arranged in the middle of the night.

"People get tired, and I suspect there are human errors along the way," he said. "Hopefully you have systems in place that catch them."